Asthma : a nursing care

Alfrina Hany

Medical Surgical Nursing B, March 2014

Learning Objectives

General

After following this subject the students will be able to apply the nursing care for adult clients with Asthma

Learning Objectives

Specific

The Students will be able to :

Define, categorize, identify sign & symptoms of clients with AsthmaDescribe & analyze the pathogenesis of Asthma correctlyTake the diagnostic examination for clients with AsthmaApply & manage the best nursing care to clients with Asthma

Which color are you?

COPD IS NOT ASTHMA !

COPD IS ASTHMA !

COPD

Chronic obstructive pulmonary diseaseChronic obstructive lung disease (COLD)Chronic airflow limitation (CAL)the fourth leading cause of death in the United States, and is expected to move to third place by 2020.

Signs: Cough, Sputum, Dyspnea

COPD IS NOT ASTHMA !

Different causes Different inflammatory cells Different mediators Different inflammatory consequences Different response to treatment

Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow limitation

Global Initiative for Asthma

ASTHMA IS NOT:

Contagious Usually geneticInfectious It is a chronic diseaseA Good Excuse -- to lead a sedentary life

Affects 8% of US population

25.7 million in 2010

1:11 children

1:12 adults

8.9million office visits in 2009

1.9 million emergency room visits in 2009

479,00 hospitalizations in 2009

14.2 million missed work in 2008

http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 9/112

Epidemiology

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High cost

$56 billion/year

$3,300/person/year

Mortality

33388 deaths in the US in 2009

http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 9/12

Epidemiology

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9

Hello class

In this class room, how many of you have asthma? What questions will you ask your friend with asthma?What will you say to answer?

2 or more children are likely to have asthma

In a classroom of 30 children,

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According to the latest prevalence data for asthma in children, somewhere between 4% and 10% of children under age 18 have asthma.

Characteristics

reversible triad

wheezing

cough

dyspnea

-- Sputum

Period

diurnal

seasonal

provoking factors

Airway obstruction

congestion

constriction

tight & narrow

Related Factors

Asthma Triggers

Indoor Air PollutantsOutdoor Air PollutantsOther Types of Triggers

Not all people with asthma have the same triggers that will cause an asthma attack

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Asthma is characterized by excessive sensitivity of the lungs to various stimuli. There is increasing evidence to suggest genetics play an important role in the etiology of the disease. Apparently, environmental factors interact with inherited factors to increase the risk of asthma. Environmental triggers range from viral infections and allergies, to irritating gases and particles in the air. Each person reacts differently to the factors that may trigger asthma. Triggers include:

Indoor Air Pollutants

ChemicalsBiologicals

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Secondhand smoke triggers asthma attacks and causes lower respiratory tract infections, pneumonia and many other harmful conditions. Studies have estimated that secondhand smoke may significantly aggravate symptoms of asthma for 200,000 to 1,000,000 children each year.

Combustion Products (aside from tobacco smoke) include carbon monoxide, nitrogen dioxide, and sulfur dioxide. Sources of combustion products include stoves, furnaces, dryers, fireplaces and heaters.

Biologicals include substances such as waste matter and dander from living organisms (both pets and pests), pollen, molds, mildew, dust mites, bacteria and viruses.

Volatile Organic Compounds are emitted as gases from solids or liquids. Sources include formaldehyde-containing building materials, as well as an array of home and office products ranging from cosmetics, paints, and cleaners to pesticides, copiers and printers, glues and adhesives, and craft supplies.

Chemical IrritantsCigarette smoke and wood smokeScented products such as hair spray, cosmetics, and cleaning productsStrong odors from fresh paint or cookingAutomobile fumes and air pollutionChemicals such as pesticides and lawn treatmentsDust, mold, cockroaches

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Irritants cause asthma symptoms, but are not IgE mediated.

Cigarette smoke contains 4,000 substances, with 40 of them linked to cancer. Secondhand smoke can trigger an asthma exacerbation, pneumonia, and bronchitis or cause the development of asthma in young children. Young children also have more ear infections with secondhand smoke exposure. Smoking should not be allowed in the home or in the car. If someone needs to smoke, they should smoke outside.

Limit prolonged outdoor physical activity on air pollution alert days. Encourage people to refuel their cars and use their gas powered lawn equipment after 7 pm on air pollution alert days.

Other substances such as oil based paints, cleaning products, or hair spray trigger asthma.

BIOLOGIC IRRITANTS

Infections in the upper airways, such as colds (a common trigger for both children and adults)ExerciseStrong expressions of feelings (crying, laughing)Changes in weather and temperature

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Upper respiratory infections in young children are the most common cause of asthma exacerbations.

Exercise dries and cools the airways, triggering more airway closures.

Crying or laughing can trigger asthma symptoms when the asthma is not under good control.

Weather conditions, such as cold weather, can make asthma worse.

Outdoor Air Triggers

Ozone (O3)Particulate matter

Sulfur dioxide (SO2)

Nitrogen dioxide - vehicle exhaust

Outdoor pollens and mold

Additional Triggers

Viral upper respiratory infectionsExerciseMedicationsDietCold air

Is There A Cure For Asthma?

Asthma cannot be cured,

but it can be controlled.

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Classification

Asma bronkial tipe non atopi (intrinsik)Asma bronkial tipe atopi (Ekstrinsik). Asma bronkial campuran (Mixed)

Tipe non atopi (intrinsik)

Keluhan tidak ada hubungannya dengan paparan (exposure) terhadap alergen sifat-sifatnya adalah:

- timbul setelah dewasa

- keluarga tidak ada yang menderita asma

- penyakit infeksi

- pekerjaan atau beban fisik

- perubahan cuaca atau lingkungan peka

Tipe atopi (Ekstrinsik).

Keluhan ada hubungannya dengan paparan terhadap alergen lingkungan yang spesifik.Kepekaan ini biasanya dapat ditimbulkan dengan uji kulit atau provokasi bronkial. timbul sejak kanak-kanak, pada famili ada yang menderita asmaDi Inggris jelas penyebabnya House Dust Mite, di USA tepungsari bunga rumput.

Asma bronkial campuran (Mixed)

Pada golongan ini, keluhan diperberat baik oleh faktor-faktor intrinsik maupun ekstrinsik.

Classification of Asthma Severity

Days with Nights with Lung Function

symptomssymptoms FEV1 PEF %

Step 4

Severe ContinualFrequentFEV1 PEF = 5 times per monthFEV1 PEF 60-80%

Step 2

Mild persistent3-6 times/week 3-4 times per monthFEV1 PEF > 80%

Step 1

Mild intermittent

Diagnostic Tests

CXR INFILTRATESSEVERE BLOOD EOSINOPHILIAORGANISM IN SPUTUMBLOOD GAS ANALYSISLUNG FUNCTION TEST

reveal a decreased forced expiratory volume, increased residual volume from air trapping and decreased vital capacity (max amount of air exhaled)

SKIN TEST to identify allergensPULSE OXYMETRI

LUNG FUNCTION

the values on a pulmonary function test must tell you the % of predicted valuethe absolute values have too much variabilitylung function tests can be modifiedvaries with body size, age, lung compliance

LUNG FUNCTION

Vital capacity - air volume that can be expelled from lungs after deep breathFEV1 - forced expiratory volume in 1 secPEF - peak expiratory flow rate

Take a deep breath and blow out

it lasts about 4 - 5 seconds

you expel about 4 L Vital capacity

about 3L is expelled in first secondFEV1

PATHOPHYSIOLOGY

How Airways Narrow

Constriction

Narrow

Inflammation

Mucus produced

Congesti

Tightness

3 Components of an Asthma Attack

1. Bronchospasm

The smooth muscles that wrap around the windpipe (bronchi) tighten, reducing the size of the airway.

normal

Asthma attack

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Use sponge roller for demonstration

3 Components of an Asthma Attack

2. Inflammation

The mucosal lining of the windpipe becomes inflamed and swells, thereby reducing the size of the airway even further.

3. Mucus

Increased mucus production takes up more space; now the airway is very constricted.

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Use sponge roller for demonstration

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

I am familiar with the most current asthma treatment guidelines?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

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Asthma Medications

Long-term Controllers

Used to control and prevent asthma symptomsMust be taken dailyCorticosteroids; Cromolyn Sodium; Long Acting beta agonist; Leucotriene modifiers; methylxantine

Quick-Relief

Provides quick relief of an acute asthma episode by opening up the bronchiolesUsed as needed for symptoms and before exercise Short-acting beta2 agonists;anticholinergic; systemic steroid

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There are two main medications used for asthma. They are called long term controllers and quick relief (or rescue). The long term controller medication is sometimes called a preventer. The quick relief medication is sometimes called a reliever. It is important for the child and family to understand the difference in the medicines.

Quick relief medicines are used as needed for symptoms and before exercise.

Pharmacologic Therapy

Long-term control medicationscorticosteroids inhaled form systemic steroids used to gain prompt control of disease when initiating inhaled txcromolyn sodium or nedocromil mild-to-moderate anti-inflammatory medications (may be used initially in children)preventive tx. prior to exercise or unavoidable exposure to known allergens

Long-term control medicationsLong-acting beta2-agonistsused concomitantly with anti-inflammatory meds for long-term symptom control especially nocturnal symptomsprevents exercise-induced bronchospasmMethylxanthines sustained-release theophylline used as adjuvant to inhaled steroids for prevention of nocturnal symptoms

Long-term control medicationsLeukotriene modifiers zafirlukast - leukotriene receptor antagonistzileuton - 5-lipoxygenase inhibitor is alternative therapy to low doses of inhaled steroids/nedocromil/cromolyn alternative tx to low dose inhaled steroids/cromolyn/nedocromilrecommended for >12yrs with mild persistent asthma. Further study needed

Quick relief medicationsShort acting beta2-agonists - relief of acute symptoms Anticholinergics - may provide additive benefit to beta2 drugs in severe exacerbation. May be alternative to beta2-agonistsSystemic steroids - moderate-to-severe persistent asthma in acute exacerbations or to prevent recurrence of exacerbations

Components of Severity2007 NAEPP Guidelines, EPR-3 Section 3, pg 74.Classification of Asthma Severity(Youths 12 years of age and adults)IntermittentPersistentMildModerateSevereImpairmentNormal FEV1/FVC: 8-19yr 85% 20-39yr 80% 40-59yr 75% 60-80yr 70%Symptoms2 days/week>2 days/week but not dailyDailyThroughout the dayNighttime awakenings2x/month3-4x/month>1x/week but not nightlyOften 7x/weekShort-acting 2-agonist use for symptom control (not EIB prevention)2 days/week>2 days/week but not >1x/dayDailySeveral times per dayInterference with normal activityNoneMinor limitationSome limitationExtremely limitedLung functionNormal FEV1 between exacerbationsFEV1 >80% predictedFEV1/FVC normalFEV1 80% predictedFEV1/FVC normalFEV1 >60% but < 80% predictedFEV1/FVC reduced 5%FEV1 < 60% predictedFEV1/FVC reduced >5%RiskExacerbations requiring oral systemic corticsteroids0-1/year2/year Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severe category.Relative annual risk of exacerbation may be related to FEV1

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Intermittent

Asthma

Persistent Asthma: Daily Medication

Consult asthma specialist if step 4 care or higher is required.

Consider consultation at step 3.

Step 1

Preferred:

SABA PRN

Step 2

Preferred:

Low dose ICS

Alternative: Cromolyn, LTRA, Nedocromil or Theophylline

Step 3

Preferred:

Low-dose ICS + LABA

OR Medium dose ICS

Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton

Step 4

Preferred:

Medium Dose ICS + LABA

Alternative:

Medium-dose ICS + either LTRA, Theophylline, or Zileuton

Step 5

Preferred:

High

Dose ICS + LABA

AND

Consider Omalizumab for patients who have allergies

Step 6

Preferred:

High dose ICS + LABA + oral corticosteroid

AND

Consider Omalizumab for patients who have allergies

Each Step: Patient Education and Environmental Control and management of comorbidities

Steps 2 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma

2007 NAEPP Guidelines, EPR-3 Section 4, pg 343.

Assess control

STEP-WISE APPROACH TO THERAPY

Step down if possible

(and asthma is well controlled at least 3 months)

Step up if needed

(first, check adherence, environmental control & comorbid conditions)

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Components of Control2007 NAEPP Guidelines, EPR-3 Section 3, pg 77.Classification of Asthma Control(Youths 12 years of age and adults)Well-ControlledNot Well-ControlledVery Poorly ControlledImpairmentSymptoms2 days/week>2 days/weekThroughout the dayNighttime awakening2x/month1-3x/week4x/weekInterference with normal activityNoneSome limitationExtremely limitedFEV1 or peak flow>80% predicted/personal best60-80% predicted/personal best

Stepping UP (EPR 3, 2007)

Asthma NOT WELL CONTROLLEDReview adherence, inhaler technique, environmental control, co morbid conditionsStep up 1 step and reevaluate in 2-6 weeksAsthma VERY POORLY CONTROLLEDReview adherence, inhaler technique, environmental control, co morbid conditionsConsider short course of oral steroidStep up 1 or 2 steps and reevaluate in 2 weeks

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Stepping DOWN (GINA, 2011)
(asthma is controlled >3months)

If pt on Medium-High doseReduce dose 50% at 3 month intervals (Evidence B)If control achieved on low doseSwitch to once daily (Evidence A)If pt taking ICS + LABAReduce ICS dose 50% + LABA (Evidence B)Once control achieved on low dose + LABA (Evidence D)Attempt to d/c LABAIf pt taking ICS + other controllerReduce ICS dose 50% + other controller (Evidence D)Once control achieved on low dose + other controller (Evidence D)Attempt to d/c other controllerIf pt on lowest dose of controller and no symptoms for 1 year Attempt to d/c controller

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http://hamptonroads.com/files/images/6161.jpg. accessed 3/08

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I can instruct a patient on how to properly use an MDI?

Yes

No

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MDI-technique Is significant

Lindgren et al. Eur J Resp Dis 1987;70:93-98.56% of patients made errors in MDI-technique which resulted in a 30% decrease in bronchodilation versus control (p

MDI technique

Plaza et al. Resp 1998;65:195-1989% of patients, 15% of nurses, and 28% of physicians showed correct MDI-technique.Interiano et al. Arch Intern Med 1993;153:81-8565% of patients, 39% of housestaff, 82% of nurses were categorized as having poor MDI-technique.

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Asthma Management Plan

Goals of therapyPrevent symptomsMaintain (near) normal PFMaintain normal activity Prevent exacerbations & minimize ER visits/hospitalizationsOptimal drug tx, minimal problems Patient/family satisfaction

Recommended monitoringS & S PFTQuality of life/functional statusExacerbations DrugsPatient/provider communication & satisfactionMonitor using clinician assessment/pt. self-assessment Spirometry testsInitial assessmentPost tx after patients symptoms and PF stabilizeMinimally Q 1-2 yrs

Written action plan based on:Signs & symptoms &/or PEF Patient education:Recognition need for additional therapy

Asthma Action Plan

Peak Flow MeasurementsAsthma Symptoms, Asthma Medications, Relaxation exerciseEmergency Numbers

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Asthma Action Plan (asthma control plan) is a written plan used to manage acute exacerbations of asthma. This is also a joint effort between the patient and their physician and is specific to the individual. An asthma Action plan should include:

Peak flow numbers measure how well the patient is breathing. If the peak flow numbers drop, it means they are having trouble breathing.Asthma Symptoms such as: coughing, wheezing, shortness of breath and chest tightness. The action plan should tell the patient what to do when they are awakened in the night with symptoms and when to increase treatments to manage asthma symptoms. The plan should be based on the severity or seriousness of these symptoms.Asthma Medications include different types that the patient should take to control and treat symptoms. You will need to develop instructions about when to take asthma medications.Emergency Telephone Numbers and Location of Emergency Care

Crisis Plan for Asthma

Begin this plan when I have:

These Symptoms:Taking these medications:

____________________________________

____________________________________

Call my doctor:

Name: _______________Phone number: _________________

If I cannot reach my doctor immediately:

Take ______________________________________________________

If I have severe symptoms or I am getting worse very quickly:

Go to the emergency room if within ten minutes distance:

Location of emergency room ________________________

Contact and emergency transport system____________________________________________

Phone number _____________________________

Name of system ________________________

Planning for Travel ____________________________________________________________________

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Key Elements of Asthma Therapy

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NURSING CARE

ASSESSMENT

SesakRR > 20x/menitOtot bantuWheezingRhonkiSaturasi oksigenBGAPEV

DIAGNOSIS

1. Impaired gas exchange

2. Ineffective airway clearance

3. Ineffective breathing pattern

4. Impaired spontaneous ventilation

5. Ineffective tissue perfusion

Journal Corner

Common Cold, Pregnancy, AsthmaGINA, Issued Feb 3, 2014Germany513 pregnant mother526 childrenMonitored frequentlyResult

Implications:

TriggerPercentageassessment

DIAGNOSIS

6. Latex allergy response

7. Contamination

8. Readiness for enhanced coping

9. Readiness for enhanced family coping

10. Electrolyte imbalance

11. anxiety

12. Readiness for enhanced self health management

13. Insomnia

14. Ineffective protection

15. Relocation stress syndrome

16. Impaired skin integrity

17. Risk for suffocation

ineffective Airway Clearance may be related to increased production and retained pulmonary secretions, bronchospasm, decreased energy, fatigue,

possibly evidenced by wheezing,difficulty breathing, changes in depth and rate of respirations, use of accessory muscles, and persistent ineffective cough with or without sputum production.

impaired Gas Exchange may be related to altered delivery of inspired oxygen, air trapping

possibly evidenced by dyspnea, restlessness, reduced tolerance for activity, cyanosis, andchanges in arterial blood gases and vital signs.

Anxiety [specify level] may be related to perceived threat of death,

possibly evidenced by apprehension, fearful expression, and extraneous movements

Nursing Diagnosis

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by fatigue and exertional dyspnea.risk for Infection: risk factors may include presence of atmospheric pollutants, environmental contaminants in the home (e.g., smoking or secondhand tobacco smoke).

NURSING OUTCOMES/EVALUATION CRITERIA

Respiratory Status: Airway Patency: Open, clear tracheobronchial passages for air exchangeAspiration Control: Personal actions to prevent the passage of fluid and solid particles into the lungCognition: Ability to execute complex mental processes

Client Will (Include Specific Time Frame)

Maintain airway patency.

Expectorate or clear secretions readily.

Demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, arterial blood gas [ABG] results within client norms).

Verbalize understanding of cause(s) and therapeutic management regimen.

Demonstrate behaviors to improve or maintain clear airway.

Identify potential complications and how to initiate appropriate preventive or corrective actions.

Nursing Interventions Criteria

Airway Management: Facilitation of patency of air passagesRespiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchangeCough Enhancement: Promotion of deep inhalation by the patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air

Priority 1: To maintain adequate, patent airway

Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma)Evaluate amount and type of secretions being produced. Excessive &/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function,is very young/elderly,is developmentally delayed, has restrictive/obstructive lung disease, is mechanically ventilated. Note ability to, and effectiveness of, cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury (SCI), brain injury, postsurgery and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.Suction (nasal, tracheal, oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways

Priority 2 :To mobilize secretions

Elevate head of the bed or change position, as needed. Elevation or upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfortPosition appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs.Encourage and instruct in deep-breathing and directed-coughing exercises; teach (presurgically)& reinforce (postsurgically) breathing&coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.

Conclusions

Asthma is a chronic disease when improperly treated can lead to poor outcomesSuccessful asthma therapy requires regular assessments of symptom control and medication adherenceProper inhaler technique is critical to successful asthma therapyAsthma education requires continuous reinforcementNursing care should include asthma management/guidelines

Resources

Smeltzer et al. 2010. Brunner & Suddarths Textbook of Medical Surgical Nursing, 12th edition. Lippincott William WilkinsDoengoes, Moorhouse, Murr. 2013. Nursing Diagnosis Manual. 4th Edition. USA:FA Davis CompanyWilliam,Hopper.2007. Understanding Medical Surgical NursingNANDA 2012-2014Nursing Outcome Criteria (NOC)Nursing Intervention Criteria (NIC)Asthma Guidelines http://www.ginasthma.comCommon Colds during Pregnancy may lead to Childhood Asthma.http://www.acaai.org/allergist/news/New/Pages/CommonColdsduringPregnancymayleadtoChildhoodAsthma.aspxNational Asthma Education and Prevention Program -- http://www.nhlbi.nih.gov

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Scenario

Tn. Roim, 24 th, dibawa keluarga ke RS dengan keluhan utama sesak napas, batuk berdahak warna putih agak kental dan sulit dikeluarkan. Klien mengatakan sesak sejak 2 hari lalu dan bertambah berat pada malam hari atau hawa dingin. Klien juga mengatakan cemas akan kondisinya karena tidak pernah muncul keluhan seperti ini. PF: tampak sesak dan cemas, CM, TD 120/80 mmHg, N 120x/mnt, RR 30x/mnt, napas cuping hidung, wheezing seluruh lapang paru. Klien tampak bingung dan tidak tahu bagaimana cara menangani keluhan atau menggunakan MDI.

YOU ARE NURSE IN CHARGE, WHAT WILL YOU DO?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

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Yes

No

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